GROUND WATER ASSESSMENT FORMS

Checklist for Drinking Water Source Assessment

Ground Water Source

Public water system: ID No.:

Name of source: ID No.:

Assessment date: Assessment conducted by

Water System Contact Name: Phone #:

Water System Contact Address:

The following information should be contained in the drinking water source assessment submittal.

Delineation of groundwater protection zones

Source Data Sheet (select appropriate form)

Well Data Sheet
Spring Data Sheet
Horizontal Well Data Sheet

Possible Contaminating Activities (PCA) inventory form

Assessment map with source location and protection zone

Additional maps (optional) (e.g. local maps of zones and PCAs, recharge area maps, or maps
indicating direction of ground water flow)

Means of Public Availability of Report (indicate those that will be used)

Notice in the Consumer Confidence Report* (minimum)

Copy in regulatory agency (DHS or LPA) office (minimum)
Copy in public water system office (recommended)
Copy in public library/libraries
Internet (indicate Internet address: __________________________)
Other (describe)

*The CCR should indicate where customers can review the assessments.

Page 1
 GROUND WATER ASSESSMENT FORMS

Delineation of Ground Water Protection Zones

Procedures

Three zones are delineated around a well (see specific guidance for springs and horizontal wells),
using the Calculated Fixed Radius method. The default shape of these zones is circular and the
radius of the zones is based on the Time of Travel (TOT) of water from a point in the aquifer to
the well. The three zones are defined as:
Zone A (2 year TOT)
Zone B5 (5 year TOT)
Zone B10 (10 year TOT)

For porous media aquifers (consisting primarily of rocks, sands, gravels and clays), the radius
also considers the pumping rate of the well (Q in gallons per minute), the screened interval of the
well (H in feet), and the effective porosity of the aquifer ( - assumed to be 0.2). For fractured
rock aquifers, the procedures are the same, but the radius of the zones is increased by 50%.

There are more complicated methods for determining the size, shape and location of zones.
Water systems interested in these methods should consult with a hydrogeologist or other
knowledgeable professional.

The following table has been developed to assist water systems and regulators in determining the
procedures to use in delineating protection zones.

TABLE 1
Aquifer Type of System Pumping Radius Radius Radius
Media Rate Zone A Zone B5 Zone B10
(Q gpm) (R2 feet) (R5 feet) (R10 feet)
Porous Media 600min. 1,000min. 1,500min.
Transient Noncommunity Any 600 ----- -----
Non-Transient Noncommunity 0 to 100 gpm Calculate or Refer to Table 2
Non-Transient Noncommunity > 100 gpm Calculate
Community 0 to 100 gpm Calculate or Refer to Table 2
Community > 100 gpm Calculate
Fractured Rock 900min. 1,500min. 2,250 min.
Transient Noncommunity Any 900 ----- -----
Non-Transient Noncommunity 0 to 100 gpm Calculate or Refer to Table 3
Non-Transient Noncommunity > 100 gpm Calculate
Community 0 to 100 gpm Calculate or Refer to Table 3
Community > 100 gpm Contact DHS*

Page 2
 GROUND WATER ASSESSMENT FORMS

Delineation of Ground Water Protection Zones

Public water system: ID No.:

Name of source: ID No.:

Delineation date:______________Delineation conducted by _____________________________

Equation
Porous Media Aquifers Fractured Rock Aquifers
QT
RT QT
H RT 1.5
H
RT = Radius (in feet) of zone for Time of Travel T = 3.1416
T = Time of Travel (years) (2, 5, or 10 years) = Aquifer effective porosity (default = 0.2)
Q = Pumping capacity of well (in ft3/year) H = Well screened interval (in feet) (10 min.)
(ft3/year = gpm x 70,267)

Calculations
Aquifer Material (select one) Porous Media Fractured Rock
Pumping Rate Q= gpm (if unknown use Table 2 or Table 3)
Screened Interval H= feet (if unknown assume 10%Q or use Table 2 or Table 3)
Porous Media Aquifer

Zone TOT Equation Use one or the other Minimum Value

(years) Calculated Table 2 (use larger)
Radius Radius
A 2 473 Q gpm H ft 600
B5 5 748 Q gpm H ft 1,000
B10 10 1058 Q gpm H ft 1,500

Fractured Rock Aquifer (Increase size of zones by 50%)

Zone TOT Equation Use one or the other Minimum Value

(years) Calculated Table 3
Radius Radius
A 2 709 Q gpm H ft 600
B5 5 1122 Q gpm H ft 1,000
B10 10 1586 Q gpm H ft 1,500

Page 3
 GROUND WATER ASSESSMENT FORMS

DEFAULT PROTECTION ZONES

POROUS MEDIA AQUIFERS

TABLE 2
Q H (feet) Radius Radius Radius
(default Zone A Zone B5 Zone B10
minimum) (feet) (feet) (feet)
< 10 gpm 10 600 1,000 1,500
10 to 20 gpm 10 669 1,056 1,500
21 to 30 gpm 10 819 1,295 1,832
31 to 40 gpm 10 946 1,496 2,115
41 to 50 gpm 10 1,058 1,672 2,365
51 to 60 gpm 10 1,158 1,832 2,590
61 to 70 gpm 10 1,251 1,978 2,798
71 to 80 gpm 10 1,338 2,115 2,991
81 to 90 gpm 10 1,419 2,243 3,173
91 to 100 gpm 10 1,496 2,365 3,344

FRACTURED ROCK AQUIFERS

TABLE 3
Q H (feet) Radius Radius Radius
(default Zone A Zone B5 Zone B10
minimum) (feet) (feet) (feet)
< 10 gpm 10 900 1,500 2,250
10 to 20 gpm 10 1,003 1,587 2,250
21 to 30 gpm 10 1,228 1,943 2,747
31 to 40 gpm 10 1,418 2,244 3,172
41 to 50 gpm 10 1,585 2,509 3,546
51 to 60 gpm 10 1,737 2,748 3,885
61 to 70 gpm 10 1,876 2,968 4,196
71 to 80 gpm 10 2,005 3,173 4,486
81 to 90 gpm 10 2,127 3,366 4,758
91 to 100 gpm 10 2,242 3,548 5,015

Page 4
 DELINEATING PROTECTION ZONES FOR SPRINGS
Suggested Approach

The best way to determine the protection zones for a spring is to do detailed hydrogeologic
analysis. However, if this is not feasible, the California Department of Health Services (DHS)
suggests the following method.

Step 1: Determine if the spring is under the influence of surface water (either direct or indirect).
(If this determination has been formalized with DHS, make sure to state this in the assessment
summary.) If the spring is under the direct influence of surface water, define watershed
boundaries as the outer/overall protection area. To define zones within the protection area, or to
define zones for ground water springs, proceed with the following steps.

Step 2: Determine the maximum discharge rate of the spring in gallons per minute (gpm). If the
discharge rate is not known, and can be assumed to be less than 20 gpm, proceed to the next step.
Otherwise, estimate the discharge rate using previously released guidance.

Step 3: Determine, if possible, the approximate thickness of the aquifer from which the spring
receives water. If this information isn't available, move on to the next step.

Step 4: Determine an equivalent 'length of screened interval' for the spring. (It is understood
that springs dont have a screened interval, but the intent is to estimate the thickness of the
aquifer that is available to contribute flow). Use 10% of the thickness of the aquifer OR 10% of
the discharge rate in gpm, whichever is less. Regardless, do not use less than 10 feet.

Step 5: Assume an effective porosity of 0.20 (20%)

Step 6: Calculate the size of the protection zones for the 2, 5 and 10-year travel times (Zones A,
B5 and B10), using the Calculated Fixed Radius method. Use the discharge rate, 'length of
screened interval', and effective porosity as described above. If this is a transient system, define
only the 2 year time of travel. If the discharge rate is less than 20 gpm, use the minimum
distances in the DWSAP program.

Step 7: If the spring is located in fractured rock increase the size of the zones by 50%.

Step 8: Locate the zones on a USGS quad map. The shape of the zones may be different than
for wells, because the springs flow by gravity. Locate the elevation of the spring outlet and draw
a topographic contour line at the same elevation. Place the center of the zones at the spring
outlet. Draw three zones (one for transient system sources) as semi-circles around the spring
outlet. The down gradient limit of the zones is the contour line at the elevation of the outlet (see
illustration).

Step 9: Review the delineation and see if it makes sense. Do the protection zones overlap a
significant water body? If the water body is up gradient, the spring may be under the influence
of surface water.

(See illustrations next page)

Delineation of Protection Zones for Springs

Direction of flow

Zone B10

Zone B5

Zone A

Spring

Direction of flow

Zone B10

Zone B5

Zone A

Spring
 DELINEATING PROTECTION ZONES FOR HORIZONTAL WELLS
Suggested Approach

A horizontal well is any well that is drilled at an angle above the horizontal plane (i.e., water can
flow by gravity). The best way to determine the protection zones for a horizontal well is to do
detailed hydrogeologic analysis. However, if this is not feasible, the California Department of
Health Services (DHS) suggests the following method.

Step 1: Determine if the horizontal well is under the influence of surface water (either direct or
indirect). (If this determination has been formalized with DHS, make sure to state this in the
assessment summary). If the horizontal well is under the direct influence of surface water, define
watershed boundaries as the outer/overall protection area. To define zones within the protection
area, or to define zones for ground water horizontal wells, proceed with the following steps.

Step 2: Determine the maximum discharge rate in gallons per minute (gpm). If the discharge
rate is not known, and can be assumed to be less than 20 gpm, proceed to the next step.
Otherwise, estimate the discharge rate using previously released guidance.

Step 3: Determine, if possible, the approximate thickness of the aquifer from which the
horizontal well receives water. If this information isn't available, move on to the next step.

Step 4: Determine an approximate 'length of screened interval' for the source. Use 10% of the
thickness of the aquifer OR 10% of the discharge rate in gpm OR the length of perforated piped
in the horizontal well, whichever is less. Regardless, do not use less than 10 feet.

Step 5: Assume an effective porosity of 0.20 (20%)

Step 6: Calculate the size of the protection zones for the 2, 5 and 10-year travel times (Zones A,
B5, and B10), using the Calculated Fixed Radius method. Use the discharge rate, 'length of
screened interval' and effective porosity as described above. If this is a transient system, define
only the 2 year time of travel. If the discharge rate is less than 20 gpm, use the minimum
distances in the DWSAP program.

Step 7: If the horizontal well is located in fractured rock increase the size of the zones by 50%

Step 8: Locate the zones on a USGS quad map. The shape of the zones will be different than
for vertical wells. Locate the elevation of the pipe outlet and draw a topographic contour line at
the same elevation. Draw three zones (one for transient system sources) around the pipe outlet.
Place the center of the zones at the outlet. The zones should extend up gradient the length of the
collection piping plus the zone distance. The zones should extend to each side of the collection
piping the zone distance (see illustration). The down gradient limit of the zones is the
topographic contour line at the well outlet.

Step 9: Review the delineation and see if it makes sense. Do the protection zones overlap a
significant water body? If the water body is up gradient, the horizontal well may be under the
influence of surface water.

(See illustration next page)

Delineation of Protection Zones for Horizontal Wells
 Zone B10

Zone B5

Zone A

Direction of Slope
 WELL DATA SHEET Sheet 1 of 3
Complete as much information as possible. Leave blank if information is not available, use N.A. if not applicable.
* Indicates items required for Source Water Assessment
** Indicates additional items required for assessments and Ground Water Rule
(separate multiple entries in Actual, Estimated or
field with semi-colon) Default?
DATA SHEET GENERAL INFORMATION
System Name from DHS database
System Number from DHS database
Source of Information (well log, DHS/County files, system, etc)
Organization Collecting Information (DHS, County, System, other)
Date Information Collected/Updated
WELL IDENTIFICATION
* Well Number or Name from DHS database
* DHS Source Identification Number (FRDS ID No.)
DWR Well Log on File? ("YES" or "NO")
State Well Number (from DWR)
Well Status (Active, Standby, Inactive) from DHS database
WELL LOCATION
Latitude from DHS database
Longitude from DHS database
Ground Surface Elevation (ft above Mean Sea Level)
Street Address
Nearest Cross Street
City
County
* Neighborhood/Surrounding Area (see Note 1)
Site plan on file? ("YES" or "NO")
DWR Ground Water Basin to come from DWR
DWR Ground Water Sub-basin to come from DWR
SANITARY CONDITIONS

** Distance to closest Sewer Line, Sewage Disposal, Septic Tank (ft)

Distance to Active Wells (ft)
Distance to Abandoned Wells (ft)
Distance to Surface Water (ft)
** Size of controlled area around well (square feet)
* Type of access control to well site (fencing, building, etc)
* Surface Seal? (Concrete slab)("YES", "NO" or "UNKNOWN")
* Dimensions of concrete slab: Length(ft)/ Width(ft)/ Thick(in)
* Within 100 year flood plain? ("YES", "NO" or "UNKNOWN")
* Drainage away from well? ("YES" or "NO")
ENCLOSURE/HOUSING
Enclosure Type (building, vault, none, etc.)
Floor material
Located in Pit? ("YES" or "NO")
Pit depth (feet) (if applicable)
 WELL DATA SHEET Sheet 2 of 3
(separate multiple entries Actual, Estimated or
WELL CONSTRUCTION in field with semi-colon) Default?
Date drilled
Drilling Method
Depth of Bore Hole (feet below ground surface)
Casing Beginning Depth/Ending Depth(ft below surface);
2nd Casing Beginning Depth/Ending Depth; 3rd Casing, etc.
Casing Diameter (inches); 2nd Casing Diameter; 3rd Casing, etc.
Casing Material; 2nd Casing Material; 3rd Casing, etc.
Conductor casing used? ("YES", "NO" or "UNKNOWN") (See Note 2)
Conductor casing removed? ("YES", "NO" or "UNKNOWN")
* Depth to highest perforations/screens (ft below surface) (or
"UNKNOWN")
Screened Interval Beginning Depth/Ending Depth (ft below surface);
2nd Screened Interval Beg. Depth/Ending Depth; 3rd Screened Interval,
etc.
* Total length of screened interval (ft)
(default = 10% pump capacity in gpm) (or "UNKNOWN")
* Annular Seal?("YES", "NO" or "UNKNOWN") (See Note 3)
* Depth of Annular Seal (ft)
Material of Annular Seal (cement grout, bentonite, etc.)
Gravel pack, Depth to top (ft below ground surface)
Total length of gravel pack (ft)
AQUIFER
* Aquifer Materials
(list all that apply: sand, silt, clay, gravel, rock, fractured rock)
* Effective porosity (decimal percent) (default = 0.2) (or
"UNKNOWN")
* Confining layer (Impervious Strata) above aquifer?
("YES", "NO" or "UNKNOWN")
Thickness of confining layer, if known (ft)
Depth to confining layer, if known (ft below ground)
* Static water level (ft below ground surface)
Static water level measurement: Date/Method
Pumping water level (ft below ground surface)
Pumping water level measurement: Date/Method
WELL PRODUCTION
Well Yield (gpm)
Well Yield Based On (i.e., pump test, etc.)
Date measured
Is the well metered? ("YES" or "NO")
Production (gallons per year)
Frequency of Use (hours/year)
Typical pumping duration (hours/day)
PUMP
Make
Type
Size (hp)
* Capacity (gpm)
 WELL DATA SHEET Sheet 3 of 3
PUMP (continued)
Depth to suction intake (ft below ground surface)
Lubrication Type
Type of Power: (i.e., electric, diesel, etc.)
Auxiliary power available? ("YES" or "NO")
Operation controlled by: (i.e., level in tank, pressure, etc.)
Pump to Waste capability? ("YES" or "NO")
Discharges to: (i.e., distribution system, storage, etc.)
REMARKS AND DEFECTS (use additional sheets as necessary)

NOTES
1. Neighborhood/Surrounding Area (list all that apply): A= Agricultural, Ru =
Rural, Re = Residential, Co = Commercial,
I = Industrial, Mu = Municipal, P = Pristine, O = Other
2. Conductor Casing - Oversized casing used to stabilize bore hole during
well construction. Should be removed during installation of annular seal.
3. Annular Seal - Seal of grout in the space between the well casing and
the wall of the drilled hole. Sometimes called "sanitary seal".

Please Note:
The information on this Well Data Sheet is considered confidential.
To allow the information to be included
in the permit report, or made available subject to a public
information act request, the waiver clause below has
to to be signed and dated by the owner (public water system). In
lieu of this signature, the WDS has to be
retained in a confidential file, or the information shown in the
shaded rows has to be "blacked out."

I/We,(Name)_______________________________________,
certify that I/Weam/are the present owners of the well
described on this well data sheet. I/We have reviewed the
information presented on this well data sheet and I/We take no
exception to having the information inlcuded in the
Department of Health Services' Engineering Report. I/We
understand that by including the well data sheet in the
Engineering Report, it will be part of a public document that
can be reviewed and copied subject to the public information
act request.
,

________________________ ________________
(Signature) (Date)
 SPRING DATA SHEET Sheet 1 of 2
Complete as much information as possible. Leave blank if information is not available, use N.A. if not applicable.
* Indicates items required for Source Water Assessment
** Indicates additional items required for assessments and Ground Water Rule
(separate multiple entries in Actual, Estimated
field with semi-colon) or Default?
GENERAL INFORMATION
System Name from DHS database
System Number from DHS database
Source of Information (DHS/County files, system, etc)
Organization Collecting Information (DHS, County, System, other)
Date Information Collected/Updated
SOURCE IDENTIFICATION
* Source Name from DHS database
* DHS Source Identification Number (FRDS ID No.)
Status (Active, Standby, Inactive) from DHS database
LOCATION
Ground Surface Elevation (ft above Mean Sea Level)
Street Address
Nearest Cross Street
City
County
* Neighborhood/Surrounding Area/Land Use (see Note 1)
Site plan on file? ("YES" or "NO")
SANITARY CONDITIONS
** Distance to closest sewage facilities (ft)
Distance to Surface Water (ft)
** Size of controlled area around source (ft2)
* Type of access control to well site (fencing, building, locks, etc)
* Within 100 year flood plain? ("YES", "NO" or "UNKNOWN")
* Drainage away from source? ("YES" or "NO")
SPRING HOUSING
Housing Type (building, vault, spring box, none, etc.)
Date Constructed
Dimensions (Length/Width/Depth) (ft)
Floor material (concrete, wood, metal, etc.)
Roof material (concrete, wood, metal, etc.)
Side material (concrete, wood, metal, etc.)
Ventilation? ("YES" or "NO")
Screening? ("YES" or "NO")
Inflow Location
Outflow Location
Outlet Screen? ("YES" or "NO")
Overflow to where?
AQUIFER
* Aquifer Materials
(list all that apply: sand, silt, clay, gravel, rock, fractured rock)
* Approximate thickness of Aquifer (ft)
* Effective porosity (decimal percent) (default = 0.2) (or
"UNKNOWN")
 SPRING DATA SHEET Sheet 2 of 2
(separate multiple entries in Actual, Estimated
field with semi-colon) or Default?
SOURCE PRODUCTION
Dependable Yield (gpm)
Constancy of flow (continuous, seasonal, intermittent, etc.)
Yield Based On (i.e., metering, pump test, etc.)
Date measured
Is the source metered? ("YES" or "NO")
Production (gallons per year)
Frequency of Use (hours/year)
Typical usage duration (hours/day)
Operation controlled by: (i.e., level in tank, pressure, etc.)
Discharges to: (i.e., distribution system, storage, etc.)
Discharged to system via pump (see below) or gravity?
PUMP (If applicable)
Make
Type
Size (hp)
* Capacity (gpm)
Lubrication Type
Type of Power: (i.e., electric, diesel, etc.)
Auxiliary power available? ("YES" or "NO")

REMARKS AND DEFECTS (use additional sheets as necessary)

NOTES
1. Neighborhood/Surrounding Area (list all that apply):
A= Agricultural, Ru = Rural, Re = Residential, Co = Commercial, I = Industrial, Mu = Municipal, P = Pristine, O = Other
 HORIZONTAL WELL DATA SHEET Sheet 1 of 2
Complete as much information as possible. Leave blank if information is not available, use N.A. if not applicable.
* Indicates items required for Source Water Assessment
** Indicates additional items required for assessments and Ground Water Rule
(separate multiple entries in Actual, Estimated
field with semi-colon) or Default?
GENERAL INFORMATION
System Name from DHS database
System Number from DHS database
Source of Information (well log, DHS/County files, system, etc)
Organization Collecting Information (DHS, County, System, other)
Date Information Collected/Updated
SOURCE IDENTIFICATION
* Source Name from DHS database
* DHS Source Identification Number (FRDS ID No.)
DWR Well Log on File? ("YES" or "NO")
State Well Number (from DWR)
Well Status (Active, Standby, Inactive) from DHS database
SOURCE LOCATION
Ground Surface Elevation (ft above Mean Sea Level)
Street Address
Nearest Cross Street
City
County
* Neighborhood/Surrounding Area (see Note 1)
Site plan on file? ("YES" or "NO")
SANITARY CONDITIONS
** Distance to closest sewage facilities (ft)
Distance to Active Wells (ft)
Distance to Abandoned Wells (ft)
Distance to Surface Water (ft)
** Size of controlled area around well (square feet)
* Type of access control to well site (fencing, building, etc)
* Surface Seal? (Concrete slab)("YES", "NO" or "UNKNOWN")
* Dimensions of concrete slab: Length(ft)/ Width(ft)/ Thick(in)
* Within 100 year flood plain? ("YES", "NO" or "UNKNOWN")
* Drainage away from well? ("YES" or "NO")
ENCLOSURE/HOUSING
Enclosure Type (building, vault, none, etc.)
Floor material
Located in Pit? ("YES" or "NO")
Pit depth (feet) (if applicable)
WELL CONSTRUCTION
Date drilled
Drilling Method
Length of Well (feet)
Number of pipes
Casing Diameter (inches)
Casing Material
* Total length of perforated interval (ft) (or "UNKNOWN")
 HORIZONTAL WELL DATA SHEET Sheet 2 of 2
(separate multiple entries in Actual, Estimated
field with semi-colon) or Default?
WELL CONSTRUCTION (Continued)
* Annular Seal?("YES", "NO" or "UNKNOWN") (See Note 3)
* Length of Annular Seal (ft)
Material of Annular Seal (cement grout, bentonite, etc.)
AQUIFER
* Aquifer Materials
(list all that apply: sand, silt, clay, gravel, rock, fractured rock)
* Effective porosity (decimal percent) (default = 0.2) (or
"UNKNOWN")
* Confining layer (Impervious Strata) above aquifer?
("YES", "NO" or "UNKNOWN")
Thickness of confining layer, if known (ft)
Depth to confining layer, if known (ft below ground)
* Static water level (ft below ground surface)
Static water level measurement: Date/Method
WELL PRODUCTION
Well Yield (gpm)
Well Yield Based On (i.e., pump test, etc.)
Date measured
Is the well metered? ("YES" or "NO")
Production (gallons per year)
Frequency of Use (hours/year)
Typical pumping duration (hours/day)
PUMP
Make
Type
Size (hp)
* Capacity (gpm)
Depth to suction intake (ft below ground surface)
Lubrication Type
Type of Power: (i.e., electric, diesel, etc.)
Auxiliary power available? ("YES" or "NO")
Operation controlled by: (i.e., level in tank, pressure, etc.)
Pump to Waste capability? ("YES" or "NO")
Discharges to: (i.e., distribution system, storage, etc.)
REMARKS AND DEFECTS (use additional sheets as necessary)

NOTES
1. Neighborhood/Surrounding Area (list all that apply):
A= Agricultural, Ru = Rural, Re = Residential, Co = Commercial, I = Industrial, Mu = Municipal, P = Pristine, O = Other
2. Conductor Casing - Oversized casing used to stabilize bore hole during well construction. Should be removed during
installation of annular seal.
3. Annular Seal - Seal of grout in the space between the well casing and the wall of the drilled hole. Sometimes called
"sanitary seal".
 Possible Contaminating Activities (PCA) Inventory Form

Ground Water Source

Public water system name: ID No.

Name of drinking water source: ID No.

Inventory date: Inventory conducted by:

Indicate PCAs pertinent to the drinking water source protection zones, from the following tables,
as applicable:

Commercial/Industrial

Residential/Municipal

Agricultural/Rural

Other (required for all)

Proceed to appropriate checklist or checklists. Indicate whether the PCA is located in the zone
by placing a Y (yes), N (no), or U (unknown) in the appropriate boxes.
Example:
Zone A Zone Zone
B5 B10
Y N N
N Y U
U N N

Risk Ranking of PCAs, where VH = Very High Risk, H = High Risk, M = Moderate Risk, L =
Low Risk
 PCA Checklist COMMERCIAL/INDUSTRIAL
PCA (Risk Ranking) PCA in PCA in PCA in Comments
Zone A? Zone B5? Zone B10?
Automobile- Body shops (H)
Automobile- Car washes (M)
Automobile- Gas stations (VH)
Automobile- Repair shops (H)
Boat services/repair/ refinishing (H)
Chemical/petroleum pipelines (H)
Chemical/petroleum processing/storage
(VH)
Dry cleaners (VH)
Electrical/electronic manufacturing (H)
Fleet/truck/bus terminals (H)
Furniture repair/ manufacturing (H)
Home manufacturing (H)
Junk/scrap/salvage yards (H)
Machine shops (H)
Metal plating/ finishing/fabricating (VH)
Photo processing/printing (H)
Plastics/synthetics producers (VH)
Research laboratories (H)
Wood preserving/treating (H)
Wood/pulp/paper processing and mills (H)
Lumber processing and manufacturing (H)
Sewer collection systems (H, if in Zone A,
otherwise L)
Parking lots/malls (>50 spaces) (M)
Cement/concrete plants (M)
Food processing (M)
Funeral services/graveyards (M)
Hardware/lumber/parts stores (M)
Appliance/Electronic Repair (L)
Office buildings/complexes (L)
Rental Yards (L)
RV/mini storage (L)
 PCA Checklist RESIDENTIAL/MUNICIPAL
PCA (Risk Ranking) PCA in PCA in PCA in Comments
Zone A? Zone B5? Zone B10?
Airports - Maintenance/ fueling areas (VH)
Landfills/dumps (VH)
Railroad yards/ maintenance/ fueling areas
(H)
Septic systems - high density (>1/acre)
(VH if in Zone A, otherwise M)
Sewer collection systems (H, if in Zone A,
otherwise L)
Utility stations - maintenance areas (H)
Wastewater treatment plants (VH in Zone
A, otherwise H)
Drinking water treatment plants (M)
Golf courses (M)
Housing - high density (>1 house/0.5
acres) (M)
Motor pools (M)
Parks (M)
Waste transfer/recycling stations (M)
Apartments and condominiums (L)
Campgrounds/ Recreational areas (L)
Fire stations (L)
RV Parks (L)
Schools (L)
Hotels, Motels (L)
 PCA Checklist AGRICULTURAL/RURAL
PCA (Risk Ranking) PCA in PCA in PCA in Comments
Zone A? Zone B5? Zone B10?
Grazing (> 5 large animals or equivalent
per acre) (H in Zone A, otherwise M)
Concentrated Animal Feeding Operations
(CAFOs) as defined in federal regulation1
(VH in Zone A, otherwise H)
Animal Feeding Operations as defined in
federal regulation2 (VH in Zone A,
otherwise H)
Other Animal operations (H in Zone A,
otherwise M)
Farm chemical distributor/ application
service (H)
Farm machinery repair (H)
Septic systems - low density (<1/acre) (H
in Zone A, otherwise L)
Lagoons / liquid wastes (H)
Machine shops (H)
Pesticide/fertilizer/ petroleum storage &
transfer areas (H)
Agricultural Drainage (H in Zone A,
otherwise M)
Wells - Agricultural/ Irrigation (H)
Managed Forests (M)
Crops, irrigated (Berries, hops, mint,
orchards, sod, greenhouses, vineyards,
nurseries, vegetable) (M)
Fertilizer, Pesticide/ Herbicide Application
(M)
Sewage sludge/biosolids application (M)
Crops, nonirrigated (e.g., Christmas trees,
grains, grass seeds, hay, pasture) (L)
(includes drip-irrigated crops)
 PCA Checklist OTHER ACTIVITIES
PCA (Risk Ranking) PCA in PCA in PCA in Comments
Zone A? Zone B5? Zone B10?
NPDES/WDR permitted discharges (H)
Underground Injection of
Commercial/Industrial Discharges (VH)
Historic gas stations (VH)
Historic waste dumps/ landfills (VH)
Illegal activities/ unauthorized dumping (H)
Injection wells/ dry wells/ sumps (VH)
Known Contaminant Plumes (VH)
Military installations (VH)
Mining operations - Historic (VH)
Mining operations - Active (VH)
Mining - Sand/Gravel (H)
Wells - Oil, Gas, Geothermal (H)
Salt Water Intrusion (H)
Recreational area - surface water source
(H)
Underground storage tanks - Confirmed
leaking tanks (VH)
Underground storage tanks -
Decommissioned - inactive tanks (L)
Underground storage tanks - Non-
regulated tanks (tanks smaller than
regulatory limit) (H)
Underground storage tanks - Not yet
upgraded or registered tanks (H)
Underground storage tanks - Upgraded
and/or registered - active tanks (L)
Above ground storage tanks (M)
Wells - Water supply (M)
Construction/demolition staging areas (M)
Contractor or government agency
equipment storage yards (M)
Dredging (M)
Transportation corridors - Freeways/state
highways (M)
Transportation corridors - Railroads (M)
Transportation corridors - Historic railroad
right-of-ways (M)
Transportation corridors - Road Right-of-
ways (herbicide use areas) (M)
Transportation corridors - Roads/ Streets
(L)
Hospitals (M)
Storm Drain Discharge Points (M)
Storm Water Detention Facilities (M)
 PCA Checklist OTHER ACTIVITIES (continued)
PCA (Risk Ranking) PCA in PCA in PCA in Comments
Zone A? Zone B5? Zone B10?
Artificial Recharge Projects - Injection wells
(potable water) (L)
Artificial Recharge Projects - Injection wells
(non-potable water) (M)
Artificial Recharge Projects - Spreading
Basins (potable water) (L)
Artificial Recharge Projects - Spreading
Basins (non-potable water) (M)
Medical/dental offices/clinics (L)
Veterinary offices/clinics (L)
Surface water - streams/ lakes/rivers (L)
Wells - monitoring, test holes (L)
 Instructions for Groundwater Assessment Map

The assessment map for a groundwater source should be submitted on USGS topographic maps
(quad maps) at 1:24,000 scale. The map should show:
- Location of the source
- Protection Zones
- Significant Possible Contaminating Activities (PCAs) within the zone (optional, but
recommended)

The protection zone for groundwater sources are a set of three circles surrounding the source.
(For springs and horizontal wells, if determined to be groundwater sources, the protection zones
need not include those portions of the circles down gradient of the source.) The radius of the
protection zone is determined in the Delineation section of the assessment and depends upon the
aquifer material, well pumping rate, screened interval, and aquifer porosity.

USGS quad maps may be obtained from map or backpacking retailers. There are also several
computer software programs that include USGS quad maps.

At the discretion of the regulatory agency, the water system may request that the regulatory
agency prepare a map displaying the source and zones.

Example maps for a well source and a spring source are attached.
Example Well Assessment Map
Example Spring Assessment Map